Pharmaceutical Care and Toxicology, a Synergy in High Risk SituationLuisetto M*

European Specialist in Laboratory Medicine 29122, Milano, Italy*Corresponding author: Luisetto M, European Specialists in Laboratory Medicine 29122, Milano, Italy, Tel: 3402479620; E-mail: maurolu65@gmai.com

Received date: August 08, 22016; Accepted date: September 19, 2016; Published date: September 26, 2016

Copyright: © 2016 Luisetto M, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

The rationale of this works is to analyse relationship in field of poisoning and toxicology between pharmaceuticalcare approach in order to improve the global management of the system and improving clinical outcomes in high risksituations. Observing the roles played by clinical pharmacy in toxicology medical team we can have relevantimproving in the management of the systems. Starting from the analysis of some relevant literature we submit tointernational organization a rethinking about the toxicological medical team organization with a stabile presence ofclinical pharmacist. Poisoning therapy is a multidisciplinary bio- medical work and we have more benefit whenclinical pharmacist is permanent member of toxicology team.

Keywords: Toxicology; Antidothes; Medicinal laboratory; Clinicalpathology; Poison centre

IntroductionBefore analysing the clinical ph. Role is crucial to evaluate the

various poisoning situations that can arrives in emergency department.We can have poisoning in different situation: home, works, industry,agriculture as well as drug overdoses, terroristic attack and othersituations. Poison substantives can be in contact by gastro intestinalway, respiratory way, eyes and skin, parenteral.

Poisons

Poisons can be caustic, corrosive, solvents; drugs abuse substantives,drugs, toxins, radioactive, heavy metals, gases, plants, fungus, smartdrugs, other venom bites. Self-poisoning, drug abuse, other situation asbites (poisonous snakes, spiders, scorpions), botulin us, tetanus,amanita phalloides are example of a complex world. Some poison arethe same drugs (in example paracetamol used for children in highdosage can be very hepatic toxic). Poisoning can interest adults,children or baby, elderly or pregnant. We can have single case ormultiple even: disaster situation with high number person involvedand involving different kind of substances: biological substances,verbal, chemical, nuclear.

In order to give optimal response in this complex situation there isthe need of an efficient emergency systems, diagnostic procedure andclinical therapy to be added to the adequate antidotes availability,supportive measure and also the really best knowledge in managementof the clinical cases. Multidisciplinary team gives more efficacy resultsv/s monodisciplinar way Luisetto et al. 2015 ukjpb [1]. Right antidotes,right time, but also right knowledge and skills: all this mean also rightdecision making systems. In Emergency medicine departments wehave every year several cases but only few cases with exits for thisreason the medical equip must have the multiprofessional expertize.

Antidotes are not to be considered as simply drugs, and often theusing condition (dosage, time, and posology) imply a deep knowledgein pharmacokinetics and dynamics applied to the single patientconditions. Toxicology, clinical pharmacy, and antidotes managementare discipline strictly connected in toxicological medical team works.

This process needs multidisciplinary equipment (lab toxicologist,clinical toxicologist, and pharmacist, nurse, imaging team, ICU teamand other as dialysis). Logistics of rare antidotes, communicationactivity with regional and national centre are often under hospitalpharmacy control and the pharmacist expertize plays a relevant role.

The patients critical condition imply that the single cases must betreated under the poison centre guidance according biomedicalliterature, (EBM or other reference, as guideline, protocols andprocedure, consolidated use). Even if the poisoning situation rarecondition if not correctly treated since first time can give criticalpatient’s condition (also death of patients) and the time factor is one ofthe most relevant factors to take in consideration. The medicinalchemistry, organic and inorganic chemistry, toxicology, biochemistrypathology knowledge of clinical pharmacist must to be added to theother medical team competences to improve clinical outcomes.

We can see that in example in USA some Poison Centre is directedby pharmacist (whit clinical toxicologist presence). In some casespharmacist can suggest to physicians plans and strategies for handlingexposures to toxins, chemicals, or life threatening drug interactions.The specific competence in pharmacokinetics, pharmacodynamics,metabolism, toxicology of iatrogenic substances is fundamental basesto apply correct antidotes therapy. (The pharmacist is the drug expertfor excellence and this expertize is useful in event of poisoning bydrugs). Pharmacists provide deep drug and poison information andare responsible for poison prevention initiatives (educationalprograms). They work closely with medical team in emergency roomand ICU response personnel, and other health-care organizations toensure early and up-to-date dissemination of life saving informationregarding possibly fatal drug overdose events.

Drug abuse is not a rare condition and toxicological lab data andclinical assessment are crucial phases in therapy. During the treatmentof poisoned overdosed pz clinical pharmacist works with physicians togive more chances to patients to save their life. Hospital pharmacisttakes care about antidotes hospital stokes and are applied in logistics ofthis kind of drugs (antidotes, vaccines, mabs, serum,immunoglobulin). The stokes of antidotes are choose by clinicians,toxicology physicians of emergency medicine and ICU but alsoevaluated also by hospital pharmacist.

Journal of Applied Pharmacy Luisetto, J App Pharm 2016, 8:4DOI: 10.21065/1920-4159.1000231

Review Article OMICS International

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

The management of the systems imply evaluation of costs

Direct Costs in hospitalization due to poisoning involved indiagnostic procedure. For the treatments of the cases (in example foroxygen therapy, blood therapy, antidotes others) and indirect costs asworking days lost, by patients, an incorrect diagnosis and therapyincrease these costs in high way. The hospital pharmacist rationalizesthe use and antidotes stoke preventing that some arrives in expirationdata by giving disponibility to other hospital before. In the first time inpoisoning event is crucial a description of the place to emergencyprofessional (scenario) of poisoning, collecting blister of medicine,syringe and other can help in diagnostic activity. This gives great help(in example odours, gases, chemicals). The clinical observe than theway of poisoning (GI; Parenteral, cutaneous, respiratory, eyes andother) and other relevant signs and symptoms then med lab toxicologytest, imaging, toxicological screening tests, biochemistry andematological or coagulate tests. Clinical Instrumental test (ECG, Spirometric, and blood pressure) and then using differential diagnosischoose the right treatment. Second level toxicological tests to prove thepoison presence (in example blood).

In Logistics of antidotes v/s normal drugs we have some peculiarity

Rare use of antidotes, difficult in ordering, high costs, expirationdata, reduce number of cases, long treatment in some cases, multiplecases, rapid necessity near to treat poisoning event, disaster situations.This need a special logistics system in order to assure the righttreatment to patient in very critically situations (is a pharmacist role).Antidotes are classified classify IPCS by time to have the drugs inemergency medicine (in 30 minutes, 2 hours, 6 hours). The antidotethat must be viable in 30 minutes is recommended that are stoked inemergency medicine or Intensive care unit.

These conditions need rigorous systems of logistic

Managed currently by hospital pharmacist and emergency requestare evaluated by them. In rare cases are involved in emergency logisticsalso public authorities (in example for terroristic attack) or in casesinvolved with national stokes of some antidotes (botulism).

In hospital settings we can have

Medical responsible antidotes stoke and Pharmacist responsibleantidotes stoke that works in strictly way (In collaboration with anti-poisoning centre and institution involved in emergency).

Logistics of antidotes

Emergency situation or not emergency in some cases the need ofquantity antidotes can not to be obtained from only one hospital stokesand there is the need for regional or national support (rare antiserumantibotulinum). Antidotes stoke in ex emergency, ICU, blood bank,hospital pharmacy, regional or national stokes. Tdm is often used insituation involved in toxicology so the medicine laboratory or imagingand also clinical pharmacist must have this new competence [2]. Otherpharmacist activity is involved in toxicological treatment as galenicactivity of hospital pharmacies that play a crucial role for example inmagisterial formula as paediatric dosage. Antidotes as active charcoal,starch, sodium thiosulfate and many other. Analysing the clinicalpharmacist works in last centuries we have find positive effect inclinical activities when part of medical team in stabile way (Luisetto etal.) 2016 Steps and Impacts of Pharmaceutical Care and ClinicalPharmacy Development on Clinical Outcomes 2016: A HistoricalAnalysis Compared with Results [3].

Treatment of poisoning FacesAfter emergency call, anamnestic data are collected next

toxicological data from laboratory are frequently asked. (med lab andimaging data, clinical data, treatment, monitoring Epidemiologicregister, Anamnestic, clinical data sign and symptoms, other diagnosticdata TDM, differential diagnosis, therapy, monitoring). Syndromes canhelp in differential diagnosis (cholinergic, excitatory, and depressive).The Toxic characteristics as molecular weight, t ½, clearance, VD andother kinetics and dynamics properties help in the choosing ofappropriate treatment (dialysis properties of the poison or not) and inthis faces deep Knowledge in molecular chemistry ant toxicology givegreat help. Clinical patient’s characteristics; comorbidity, age, organand apparatus state sign and symptoms (neurological status, cardiological, metabolic) drive the treatment (Med lab: emogas, lattice acid,anionic balance and other as carbossiHB, metahemoglin, haematuria,acid bases balances, respiratory profile).

Other measure and procedure currently usedOften are applied decontaminant procedures and supportive

measures: In example oxygen therapy, diuretics, plasma expanders,decontaminant measures, gastric washing, forced diuresis, colonwashing, emodialisis, peritoneal dialysis, Iperbaric oxygen,plasmapheresis, plasma exchange, washing procedures, and salinesolutions.

Antidotes pharmacist managementDefinition: From Latin antidotum, from Greek antidote medicine

taken or given to counteract a particular poison. We can have specificantidotes (acting v/s one poison) or a specific (used towards differentsubstantives), active towards one or plus substantives. They areclassified as first clinical choice, second choice or consolidate use.

Antidotes efficacy: Good evidence presence on efficacy commonlyused but other research is necessary efficacy not yet demonstrate,doubt efficacy.

Classification systems: IPCS WHO 1997 Time To Have Antidotes(30,2h,6h) and Efficacy Demonstrated International Programme OnChemical Safety Join Venture With WHO, Intern. Labour Organisationand United Nations Environment Programme Clinical Toxicol [4].

Evaluation of Antidotes: Activities of the International Programmeon Chemical Safety OMS.

Groups:

Antidotes.

Agents used to prevent absorption of poison, to enhanceelimination, or to treat symptomatologically the effects on bodyfunctions.

Other agent’s useful for the treatment of poisoning.

Antidothes and related agents considered obsolete.

The first classification was made by mechanism of actions.

JACHO 1997 GUIDELINEExpert consensus guideline for stoking of antidotes in hospital that

provides emergency care Dart RC et al ann. em med, 2009. Rare’santidote’s (in examples anti botulinum) regional, national stokesSymptomatic drugs.

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 2 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

AntidotesIndication use: According registered drugs use and by official

poisoning centre, procedure, protocols, consolidated use.Contraindications, side effects, risk - benefit balances.Contraindications: As the drugs they have this Side effects, allergy,modality of conservation efficacy, safety, time to use, total during oftherapy, mono therapy or association the clinical situation, patientsclinical data information anamnesis, toxicological data, kind ofpoisoning are other factors that drive the therapy.

Antidotes hospital stokes: In order to provide the necessaryantidote’s there are national, regional and local stokes related to localsituation (In ex industry presence). The stokes recommended (in orderto rationalize stokes reducing costs) nationally registered or producedor internationally drugs registered, officinal drugs, galenic, orphandrugs.

Hospital wards involved in stokes managementMany professionals and wards are involved in this field, in example

emergency medicine, Intensive care unit, Blood bank, pharmacy,pediatric (24 h or on call pharmacy service help the emergencymedical team in logistics and other cognitive service). Toxicologist,medicinal laboratories, chemists, nurse, clinical pharmacist,nephrologist, neurologist and other service as dialysis, imaging, andsurgery works together. Some type of poisoning is real emergences andthe efficacy of treatments depends on the rapid and correct response bythe professional involved. The pharmaceutical competencies of clinicalpharmacists must be added to the physician’s clinical toxicologyknowledge.

Other specific pharmacists competences in toxicologymedical team are

Poison centre pharmacists and toxicology lab, Pharmacokinetics,molecular and clinical toxicology. Clinical chemistry lab analysis,analytical chemistry. Target organ specific toxicity antidote’s stokesevaluation (quality-quantitative, local situation, clinician’s request)Starter dosage (and to continue the treatment). Drug text assay; exTHC, cocaine, amphetamine, barbiturate, ethanol formative programto medical equipe (pharmaceutical aspects) Adr report (specialistsupport to the physicians). Antidotes consultant and informativeactivities (pharmacology, toxicology) Side effects.

Emergency med. Pharmacist role and ICU:Monitoring antidote’s use, biomedical-toxicology documentation

web scientific database resource evaluation, poisoning biomedicaldatabase posology, registered and unregistered drug and antidote’s use,Diagnostic methods, Toxicology labH24 service (poison centre, medlab toxicology). Therapeutic index SAR Acute-retarded toxicity.

University and postgraduate pharmacy Courses: Core curriculumcan be clinical toxicology, Molecular toxicology, Environmental andoccupational toxicology, Medicinal chemistry, General and Clinicalpharmacology, General chemistry, Pharmacokinetics (VD,CLEARANCE, KINETICS, AUC, T/2, molecular weight isfundamental parameter to take in consideration). Pharmaco dynamics(action mechanism, receptor, at other). Availability of specificantidote’s TDM Nephrology and dialysis, renal failure Liver, cardiac,neurology, metabolic diseases Anaphylaxis andallergy ,Immunotherapy IG, and Vaccines status.

We observed also some curriculum studio rum of hospitalpharmacy school

Pharmacy Practice Residency the toxicology in example we can seethis program: University of Arizona Poison Information-ToxicologyRotation Oregon health and science university toxicology fellowship,University of Sothern California master in MS in MolecularPharmacology & Toxicology, University of Virginia toxicology rotation.

The Carolinas Poison Centre offers a one-year specialty residency intoxicology for a pharmacist. The residency experience includes allfacets of clinical toxicology and prepares the resident for successfulcredentialing by the American Board of Applied Toxicology (ABAT).Activities include care of the poisoned or overdosed patient, formalteaching from Medical and Pharm D toxicologists, poison centermanagement, clinical research, and manuscript preparation. Theprimary focus is recognizing, assessing, and managing toxic patients.The resident functions as an essential member of the toxicology serviceat Carolinas Medical Center. Minimum requirements include a PharmD from an accredited school of Pharmacy. Completion of a generalpharmacy practice residency is preferred but not required and manyothers.

We observed some relevant bibliography (in our opinion) and wehave found that:

Pharmacotherapy 2002 November. The critical care pharmacist: anessential intensive care practitioner: Papadopulos et al., measurableclinical effects of clinical PH. services decreased morbidity andmortality rates.

Intensive care med 2003 may the impact of critical care pharmaciston enhancing patient outcomes. Kane et al and about Pharmaceuticalcare and therapy error hospital management.

Res AP (2001) 2 COUNCIL OF EUROPE, concerning thepharmacist's role in the framework of health security “one of thepharmacist's basic functions, as expert in medicinal products, is to helpprevent avoidable iatrogenic risks".

ASHP Guidelines: "pharmacist for processing drug orders shouldhave routine access to appropriate clinical info about patient(medications allergy, diagnosis, lab values, and pregnancy status)".

The clinical pharmacist presence in medical team gives improving insome clinical outcomes (Luisetto et al., 2015 ukjpb).

Eur J Intern Med. [5]. Epub 2015 Jun 9. Drug-related problemsidentification in general internal medicine: The impact and role of theclinical pharmacist and pharmacologist Guignard et al [6].

“Patients admitted to general internal medicine wards might receivea large number of drugs and be at risk for drug-related problems(DRPs) associated with increased morbidity and mortality. This was a6-month prospective study conducted in two internal medicine wards.Physician rounds were attended by a pharmacist and a pharmacologist.An assessment grid was used to detect the DRPs in electronicprescriptions 24hr in advance. One of the following interventions wasselected, depending on the relevance and complexity of the DRPs: nointervention, verbal advice of treatment optimization, or writtenconsultation. The acceptance rate and satisfaction of prescribers weremeasured.”

“In total, 145 patients were included, and 383 DRPs were identified(mean: 2.6 DRPs per patient). The most frequent DRPs were druginteractions (21%), untreated indications (18%), over dosages (16%)

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 3 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

and drugs used without a valid indication (10%). The drugs or drugclasses most frequently involved were tramadol, antidepressants,acenocoumarol, calcium-vitamin D, statins, aspirin, proton pumpinhibitors and paracetamol.

The following interventions were selected: no intervention (51%),verbal advice of treatment optimization (42%), and writtenconsultation (7%). The acceptance rate of prescribers was 84% andtheir satisfaction was high. Pharmacotherapy expertise during medicalrounds was useful and well accepted by prescribers” [7].

Appropriate therapies for commonly encountered poisonings,medication overdoses, and other toxicological emergencies arereviewed, with discussion of pharmacists' role in ensuring their readyavailability and proper use. Poisoning is the second leading cause ofinjury-related morbidity and mortality in the United States, with morethan 2.4 million toxic exposures reported each year. Recently publishednational consensus guidelines recommend that hospitals providingemergency care routinely stock 24 antidotes for a wide range oftoxicities, including toxic-alcohol poisoning, exposure to cyanide andother industrial agents, and intentional or unintentional overdoses ofprescription medications (eg. calcium-channel blockers, β-blockers,digoxin, and isoniazid). Pharmacists can help reduce morbidity andmortality due to poisonings and overdoses by [1] recognizing the signsand symptoms of various types of toxic exposure, [2] guidingemergency room staff on the appropriate use of antidotes andsupportive therapies, [3] helping to ensure appropriate monitoring ofpatients for antidote response and adverse effects, and [4] managingthe procurement and stocking of antidotes to ensure their timelyavailability.

Pharmacists can play a key role in reducing poisoning and overdoseinjuries and deaths by assisting in the early recognition of toxicexposures and guiding emergency personnel on the proper storage,selection, and use of antidotal therapies [8].

Accidental poisoning in young children is common, but severe orfatal events are rare. This study was performed to identify the numberof such events occurring in the UK and the medications that weremost commonly responsible. Office of National Statistics mortalitydata for fatal poisoning; Paediatric Intensive Care Audit Networkadmissions database and the National Poisons Information Service forsevere non-fatal poisoning; Hospital Episode Statistics for admissiondata for implicated agents.

Between 2001 and 2013, there were 28 children aged 4 years andunder with a death registered as due to accidental poisoning by apharmaceutical product in England and Wales. Methadone was theresponsible drug in 16 (57%) cases. In the UK, 201 children aged 4years and under were admitted to paediatric intensive care withpharmaceutical poisoning between 2002 and 2012. The agent(s)responsible was identified in 115 cases, most commonlybenzodiazepines (22/115, 19%) and methadone (20/115,17%).Methadone is the most common pharmaceutical causing fatalpoisoning and a common cause of intensive care unit admissions inyoung children in the UK [9,10].

This study was conducted to evaluate the availability ofantidotes/key emergency drugs in tertiary care hospitals of the Punjabprovince, and to assess the knowledge of health care professionals inthe stocking and administration of antidotes in the propermanagement of poisoning cases. Seventeen (n=17) tertiary carehospitals of Punjab Pakistan were selected. Two performs (A and B)were designed for 26 antidotes/key emergency drugs and given to the

hospital pharmacists and physicians respectively. It was observed thatActivated Charcoal, being the universal antidote was found only in 6hospitals (41%). Digoxin Immune Fab, Edentate Calcium disodiumand Glucagon were not available in emergency department of anyhospital and even not included in the formulary of any hospital. About80% pharmacists were aware of the method of preparation of ActivatedCharcoal and 85% physicians were familiar with its route ofadministration. Data showed that tertiary care hospitals of Punjab donot stock antidotes according to national drug policy. Moreover thestudy strongly suggests the development of health care centers andprofessional by organizing antidote awareness programs, continuouseducation and record keeping of poisonous cases and availability ofemergency drugs around the clock [11].

Insufficient stocking of cyanide antidotes in US hospitals thatprovide emergency care Gasco et al. “To identify the influence ofcatchment area, trauma center designation, hospital size, subspecialistemployment, funding source, and other hospital characteristics oncyanide antidote stocking choice in US hospitals that providesemergency care. A web-based survey was sent out to pharmacymanagers through two listservs; the American Society of Health-Systems Pharmacists and the American College of Clinical Pharmacy.A medical marketing company also broadcasted the survey to 2,659individuals. We collected data on hospital characteristics (size, state,serving population, etc.,) to determine what influenced the hospital'sstocking choice.

The survey response rate was approximately 10% (n=286). Thirty-eight hospitals (16%) stocked at least 4 antidote kits. Safety profile,recommendations from a poison control center, and ease of use hadthe strongest influence on stocking decisions. Survey of 286 UShospital pharmacy managers, 38/234 (16%) hospitals had sufficientstocking of cyanide antidotes. Antidote preference was based on safety,ease of use, and recommendations by the local poison center, overcost” [12].

Adverse Effects of Common Drugs: Dietary Supplements Felix et al.“Dietary supplement-induced adverse effects often resolve quickly afterdiscontinuation of the offending product, especially in youngerpatients. The potential for unwanted outcomes can be amplified inelderly patients or those taking multiple prescription drugs; especiallywhere interactions exist with drugs metabolized by cytochrome P450enzymes. Attributing injury or illness to a specific supplement can bechallenging, especially in light of multi-ingredient products, productvariability, and variability in reporting, as well as the vastunderreporting of adverse drug reactions. Clinicians prescribing a newdrug or evaluating a patient with a new symptom complex shouldinquire about use of herbal and dietary supplements as part of acomprehensive evaluation. Clinicians should report suspectedsupplement-related adverse effects to the local or state healthdepartment, as well as the Food and Drug Administration's MedWatch program (available at https://www.safetyreporting.hhs.gov).Clinicians should consider discussing suspected adverse effectsinvolving drugs, herbal products, or dietary supplements with theircommunity- and hospital-based pharmacists, and explore patientmanagement options with medical or clinical toxicology subspecialists.Written permission from the American Academy of Family Physiciansis required for reproduction of this material in whole or in part in anyform or medium”[13].

“The paper examines the role of the clinical pharmacists as expertsof excellence in drug use and its impact in ICU that will eventuallyreflect in not only reducing mortality rates and improving clinical

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 4 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

outcomes but also lowering considerably the costs of drugs, medicaldevices, consequential costs caused by medical errors, number ofrecovery days in the hospital and more. This can be obtained by usingclinical pharmacist to guard, oversee, both adjust/correct therapies andtake a task of using a management tool, in every day ICU’s activities.Based on biomedical literature, we can observe a general improvementin different clinical outcomes and as a result a noticeable reduction inmortality rates, when a clinical pharmacist is a permanent member ofthe medical team. In brief words, we are here to help not only inincreasing life quality of the patients in need of a functional healthcaresystem, but also in removing unnecessary cost burdens, whicheventually prevents economy turmoil” [14,15].

Specific reversal agents for non-vitamin K antagonist oralanticoagulants are lacking. Idarucizumab, an antibody fragment, wasdeveloped to reverse the anticoagulant effects of dabigatran. “Weundertook this prospective cohort study to determine the safety of 5 gof intravenous idarucizumab and its capacity to reverse theanticoagulant effects of dabigatran in patients who had seriousbleeding (group A) or required an urgent procedure (group B). Theprimary end point was the maximum percentage reversal of theanticoagulant effect of dabigatran within 4 hours after theadministration of idarucizumab, on the basis of the determination at acentral laboratory of the dilute thrombin time or ecarin clotting time.A key secondary end point was the restoration of haemostasis.

This interim analysis included 90 patients who receivedidarucizumab (51 patients in group A and 39 in group B). Among 68patients with an elevated dilute thrombin time and 81 with an elevatedecarin clotting time at baseline, the median maximum percentagereversal was 100% (95% confidence interval, 100 to 100). Idarucizumabnormalized the test results in 88 to 98% of the patients, an effect thatwas evident within minutes. Concentrations of unbound dabigatranremained below 20 ng per milliliter at 24 hours in 79% of the patients.Among 35 patients in group A who could be assessed, haemostasis, asdetermined by local investigators, was restored at a median of 11.4hours. Among 36 patients in group B who underwent a procedure,normal intraoperative haemostasis was reported in 33, and mildly ormoderately abnormal haemostasis was reported in 2 patients and 1patient, respectively. One thrombotic event occurred within 72 hoursafter idarucizumab administration in a patient in whom anticoagulantshad not been reinitiated. Idarucizumab completely reversed theanticoagulant effect of dabigatran within minutes (Funded byBoehringer Ingelheim; RE-VERSE AD Clinical Trials. gov number,NCT02104947)” [16].

Diagnosis and treatment of polonium poisoning. Jefferson RD1,Goans RE, Blain PG, Thomas SH. Interest in the clinical toxicology of(210) polonium ((210) Po) has been stimulated by the poisoning ofAlexander Litvinenko in 2006. This article reviews the clinical features,diagnosis, and treatment of acute radiation syndrome (ARS) resultingfrom the ingestion of (210) Po. PHYSICAL CHARACTERISTICS:(210)Po is a high-energy alpha-emitter (radioactive half-life 138 days)that presents a radiation hazard only if taken into the body, forexample, by ingestion, because of the low range of alpha particles inbiological tissues. As a result, external contamination does not causeradiation sickness.

Ingested (210) Po is concentrated initially in red blood cells andthen the liver, kidneys, spleen, bone marrow, gastrointestinal (GI) tract,and gonads. (210) Po is excreted in urine, bile, sweat, and (possibly)breathes and is also deposited in hair. After ingestion, unabsorbed(210) Po is present in the faeces. The elimination half-life in man is

approximately 30-50 days. In the absence of medical treatment, thefatal oral amount is probably in the order of 10-30 microorganisms.

If the absorbed dose is sufficiently large (e.g., >0.7 Gy), (210) Po cancause ARS. This is characterized by a prodromal phase, in whichnausea, vomiting, anorexia, lymphopenia, and sometimes diarrhoeadevelop after exposure. Higher radiation doses cause a more rapidonset of symptoms and a more rapid reduction in lymphocyte count.The prodromal phase may be followed by a latent phase during whichthere is some clinical improvement. Subsequently, the characteristicbone marrow (0.7-10 Gy), GI (8-10 Gy), or cardiovascular/centralnervous system syndromes (>20 Gy) develop, with the timing andpattern of features dependent on the systemic dose. The triad of earlyemesis followed by hair loss and bone marrow failure is typical of ARS.Those patients who do not recover die within weeks to months,whereas in those who survive, full recovery can take many months.

Serial blood counts are important for assessing the rate of reductionin lymphocyte counts. Chromosome analysis, especially the dicentriccount, may establish radiation effects and provides an estimation ofdose. The diagnosis of (210) Po poisoning is established by thepresence of (210) Po in urine and faeces and the exclusion of otherpossible causes. In the absence of a history of exposure, diagnosis isvery difficult as clinical features are similar to those of much morecommon conditions, such as GI infections and bone marrow failurecaused, for example, by drugs, other toxins, or infections.

Good supportive care is essential and should be directed atcontrolling symptoms, preventing infections but treating those that doarise, and transfusion of blood and platelets as appropriate. Gastricaspiration or lavage may be useful if performed soon after ingestion.Chelation therapy is also likely to be beneficial, with research inanimals suggesting reduced retention in the body and improvements insurvival, although increased activity in some radiosensitive organs hasalso been reported with some chelating agents. Dimercaprol (BritishAnti-Lewisite) (with penicillamine as an alternative) is currentlyrecommended for (210)Po poisoning, but animal models also indicateefficacy for 2,3,-dimercapto-1-propanesulfonic acid, meso-dimercaptosuccinic acid, or N, N-dihydroxyethylethelene-diamine-N,N-bis-dithiocarbamate.

ResultsWe observe the activity of clinical pharmacist in ICU: Poison event

are managed often by ICU team and ASHP Guidelines “Pharmacistshould function a liason between pharmacy and staff includinganaesthesiology, surgery, antibiotic use.” Surgery wards setting,anaesthesiology Pharma. Service is relevant working place for clinicalpharmacists and in this setting clinical pharmacist participates in:

Recommendations regarding medication regiment review,appropriate antibiotic therapy and duration, drip rates and titration forvasopressor agents, IV compatibility, stability, anticoagulants and fluids(electrolytes and colloids) pharmaceutical anamnestic data collection,allergy evaluation antimicrobial surgery prophilaxis, infectious diseasetherapy: severe sepsis, septic shock protocols. Analgesia, anaesthesia,tromboprofylaxis, emergency drugs list. Risk assessment, ADRreporting medication to stop, switch ev/os Post-operativecomplication, need of therapy changes drug and med.devicesinformation service ,monitoring ADR, patient care rounds. Toxicologicemergencies, antidothes, support therapies, decontaminationsmeasures toxicology lab, target organ specific toxicity Identifyprescribing errors, evaluations most critical conditions, priority actions

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 5 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

clinical a and economical evaluations of therapy errors. Preventiveactions, risk management culture, Incident reporting, near miss Fmea-Fmeca, clinical audit-Root cause analysis, monitoring, documentingactivities drugs and Med. Devices information, education andconsulting activity (pharmaceutical and clinical pharmacy approach),updating procedure, protocols and guideline observance, development,ministerial advices following pharmaceutical anamnestic activities,allergy conditions

Technologies support: Validation therapy systems, alert, interaction,side effect, dose verify patient identification systems (RFID), dose unitssystems, informatic order compounding unit (aseptic, robotized,standardized, quality assurance).

Prontuaries policy: Rationalization.

High attention drugs procedures: Concentrated electrolytes,oncological therapy, immunosuppressive drugs, nephrotoxicantimicrobial etc. double control in critical drug therapy or in high riskdrug use checklist use (emergency drugs, antidote’s, haemoderivates)dose verify in magistral formula equip accountability, individual andorganizative responsibilities, legal implications regulatory organizationrole, advices, registered name, limitation prescription policy electronicclinical data system ebm approach, biomedical literature collaborativeteam working (assessment, causes, modify in procedure) in errorsmanagement: medical team, central pharmacy, general hospitalmanagement, insurance companies, patient organizations tdmtherapeutic drug monitoring, laboratory results stressing workingconditions (RISK MANAGEMENT) expiration data drugs control,right storage conditions shared acronyms wrong dose, too low, toohigh, wrong route, pharmaceutical form, patient, frequency, omissiondose, in understanding, no indication for therapy to start: ex.antimicrobial surgical prophylaxis therapy to stop, duplicates intherapy toxicity too high, labelling, dilution, compatibility acronymus,verbal ordering, decimal point and zero number calculation errors,unity of measurement LASA Look-alike/Sound-like low level in equipecommunication low level in updating risk management, PDCA, rootcauses analysis, Ishikawa diagram, project management.

The bibliography citied in this paper (as well as other not reportedin this work) shows that:

Often also drugs may be responsible in poisoning.

The stokes of some antidote as towards cyanide can beinappropriate.

That clinical pharmacist in medical team gives general improvementin clinical outcomes and that they can play a relevant crucial role.

That poisoning is a very specialistic disciple that can involve anexample verbal product (but also in many products from biological tochemistry, from organic and inorganic world, microbs, bites et other).

That a discipline named clinical pharmaceutical care can be theright one discipline to be added in toxicological medical team.

That hospital pharmacist must have an active role in antidotesstokes management (quali quantitative analysis).

That also for new drugs antidotes plasy a relevant aspect(idaracizumab).

That sometimes poisoning is a very complex therapy (as polonium)and we think the collaboration with clinical pharmacist can give morechances than without.

Discussion and conclusionPoisoning is a rare event often, but in some cases whit critical

consequences and so the right diagnosis and therapy is a goldenendpoint. The toxicology medical equip must be multi-professional.Observing the results of bibliography citied in this works and someuniversity toxicology programs for pharmacists when observe that theclinical pharmacist presence in stabile way in toxicologist medical teamgive improving in clinical outcomes.

Antidotes are used not often but rarely, and physicians need rapidinformation also in medicinal chemistry and toxicology field. Themanagement of the systems must involve clinical and logisticpharmacist. The pathology, toxicology, pharmacology and medicinalchemistry competence of clinical pharmacist added to the emergencyand ICU physician’s competences can be the right keywords. The skillsrequested to the clinical pharmacist in order to works in efficiently wayin toxicological medical team are: proactivity, learn about error, criticalthinking, collaborative, approach, management ability, problemsolving risk management (therapy errors management, some exampleand causes. illegible handwriting), we think that in order to have amore and efficacy inclusion of clinical pharmacist in the toxicologistequip also psychological and behaviour specific skill are usefulinstruments (Luisetto 2016 ijppr) [17].

New instruments as professional social media can give moreopportunity to meet researcher in healthcare field. Luisetto et al int.journal of economics and management sciences 2016 [18,19],Instrument to rapid share the information between healthcareprofessionals and to transfer research activities to practical settings.

References1. Luisetto (2015) Pharmacist Cognitive Service and Pharmaceutical Care:

Today and Tomorrow Outlook UKJPB UK. JPB 3: 67-72.2. Luisetto M (2016) An Open Letter to all Pharmacists: Pharmaceutical

Care, Medical Laboratory and Imaging 1.3. Luisetto (2016) Steps and Impacts of Pharmaceutical Care and Clinical

Pharmacy Development on Clinical Outcomes 2: A Historical AnalysisCompared with Results clinicans teamwork’s bulletin 1.

4. de Garbino JP, John A, Haines, Jacobsen D, Meredith T (1997) Evaluationof Antidotes: Activities of the International Programme on ChemicalSafety. Clinical Toxicolo 35: 333-343.

5. Eur J (2016) Intern Med 26: 399-406.6. Guignard B, Bonnabry P, Perrier A, Dayer P, Desmeules J et al. (2015)

Drug-related problems identification in general internal medicine: Theimpact and role of the clinical pharmacist and pharmacologist.

7. Marraffa JM, Cohen V, Howland MA (2012) Antidotes for toxicologicalemergencies: a practical review. Am J Health Syst Pharm 69: 199-212.

8. Anderson M, Hawkins L, Eddleston M, Thompson JP, Vale JA et al.(2016) Arch Dis Child, Severe and fatal pharmaceutical poisoning inyoung children in the UK. May 16. pii: archdischild-2015-309921.

9. Pak J (2016) Pharm Sci 29: 603-7.10. Arslan N, Khiljee S, Bakhsh A, Ashraf M, Maqsood I (2016) Availability

of antidotes and key emergency drugs in tertiary care hospitals of Punjaband assessment of the knowledge of health care professionals in themanagement of poisoning cases 29: 603-7.

11. Gasco L, Rosbolt MB, Bebarta VS (2013) Insufficient stocking of cyanideantidotes in US hospitals that provide emergency care. J PharmacolPharmacother 4: 95-102.

12. Felix TM, Karpa KD, Lewis PR (2015) Adverse Effects of CommonDrugs: Dietary Supplements. FP Essent 436: 31-40.

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 6 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231

13. Clinical Pharmaceutical Care: A New Management Health CareDiscipline in 2016 Ukjpb 2016 UK Journal of Pharmaceutical andBiosciences 4: 63-64.

14. Nili-Ahmadabadi B, Luisetto M, Nili-Ahmadabadi H, Nasser H, MashoriGR et al. (2016) Clinical Impact of Pharmacist Presence in ICU MedicalTeam on Mortality clinicinas teamworks bulletin 1.

15. Pollack CV Jr, Reilly PA, Eikelboom J, Glund S, Verhamme P et al. (2015)Idarucizumab for Dabigatran Reversal. N Engl J Med 373: 511-20.

16. Jefferson RD, Goans RE, Blain PG, Thomas SH (2009) Diagnosis andtreatment of polonium poisoning. Clin Toxicol (Phila) 47: 379-92.

17. Luisetto M (2016) Psychological and Behavior Skills for Ph. Care Practicein Medical Team. IJPPR 5.

18. Luisetto (2016) Professional Social Media: Instrument to Meet Researcherand Healthcare. Instruments with a Model for a New Scientific SocialNetwork intern journal of economics and management sciences Int JEcon Manag Sci 5: 3.

19. Cav pavia guideline (2016).

Citation: Luisetto M (2016) Pharmaceutical Care and Toxicology, a Synergy in High Risk Situation. J App Pharm 8: 231. doi:10.21065/1920-4159.1000231

Page 7 of 7

J App Pharm, an open access journalISSN: 1920-4159

Volume 8 • Issue 4 • 1000231